Cryopreserved amniotic membrane can be adjunct in management of conjunctival melanoma
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Conjunctival melanoma is an uncommon but aggressive ocular malignancy with high potential for metastasis, reported at 25% at 10 years and more than 30% at 15 years.
Early detection and treatment are paramount for disease control, given that delayed diagnosis can lead to disease mortality as high as 30%.
Source: Raymond I. Cho, MD, FACS, and Emily Xu, MD
Conjunctival melanoma most often presents as a pigmented or non-pigmented spot or raised mass on the bulbar, forniceal or palpebral conjunctiva. Biopsy techniques such as excisional or incisional biopsy, preferably with mapping, aid in obtaining representative tissue samples for accurate histopathological assessment.
The treatment of conjunctival melanoma typically involves surgical intervention, aiming to achieve complete tumor excision while preserving vision and minimizing the risk for local invasion, metastasis and recurrence. The specific approach depends on factors such as tumor size, location and depth of invasion.
Surgical options may include wide local excision, tumor resection with adjuvant therapy (eg, cryotherapy or topical chemotherapy) and, in advanced cases, orbital exenteration. The “no-touch” technique is considered the gold standard to avoid direct seeding of tumor cells to unaffected areas. In terms of reconstruction, surgeons may use various methods to treat large conjunctival defects after excision of conjunctival tumors, including primary closure, closure with conjunctival flaps, conjunctival autografts from the contralateral eye, oral mucosal grafts and amniotic membrane transplantation.
Role of cryopreserved amniotic membrane
Cryopreserved amniotic membrane (CAM) has emerged as a promising therapeutic option in the management of ocular surface diseases and conjunctival reconstruction. The cryopreservation process preserves the native basement membrane, maintaining its innate wound-healing modulating factors. Previous studies on amniotic membranes have demonstrated their efficacy in promoting epithelialization while minimizing inflammation, fibrosis and angiogenesis.
CAM is commercially available in various thicknesses appropriate for use in managing ocular surface disease. In the setting of conjunctival reconstruction after melanoma excision specifically, ultra-thick CAM — such as AmnioGuard (BioTissue) — can have an average thickness between 500 µm and 900 µm and has been designed with improved tensile strength that can withstand the demands of conjunctival reconstruction and heal with cosmesis in mind. In a previous study using CAM in the reconstruction of conjunctival melanoma, the most common postoperative complaint was transient discomfort, which resolved as the membrane graft healed.
Case presentation
A man in his mid-40s presented to the oculoplastics clinic with biopsy-proven malignant melanoma of the right lower eyelid. Per patient report, he previously underwent resection of his right lower eyelid due to “black spots” on his lower eyelid. On examination, he was noted to have an irregular contour with pigmented elevation over the lateral and medial lower lid, in addition to pigment throughout the lower fornix and caruncle.
The tumor-involved portion of the lower lid was resected, involving more than 95% of the lower eyelid. Abnormally pigmented areas of the palpebral and bulbar conjunctiva were excised as well. The edges of resection were treated with cryotherapy, and a temporary suture tarsorrhaphy was placed to optimize postoperative healing. A sentinel lymph node biopsy was performed under the same anesthetic and subsequently confirmed the presence of regional lymph node metastasis.
One week later, following histopathologic confirmation of clear surgical margins, the patient underwent modified Hughes flap reconstruction of the lower eyelid and conjunctival defect. An upper lid tarsoconjunctival flap was created to reconstruct the posterior lamella of the lower lid, which was covered with a full-thickness preauricular skin graft. The palpebral conjunctiva was reconstructed with a buccal mucous membrane graft. To reconstruct the bulbar conjunctival defect, a piece of trimmed AmnioGuard umbilical cord membrane was placed over the exposed Tenon’s capsule and secured into place with 8-0 polyglactin sutures and fibrin sealant.
The Hughes flap was divided 2 weeks postoperatively, but due to the patient’s smoking, the flap failed 2 weeks later, and a revision of the reconstruction with a Tenzel flap was performed. Additional grafting with AmnioGuard was performed over the inferomedial and inferolateral conjunctival fornices.
The patient underwent adjuvant topical treatment with topical mitomycin C and systemic treatment for the metastatic disease with immune checkpoint inhibitors. At 2 years’ follow-up, the eyelid and conjunctival reconstruction was well healed, with mild symblepharon and shortening of the medial conjunctival fornix. No diplopia was reported by the patient.
Conclusion
CAM has emerged as a valuable adjunct to the surgical management of conjunctival melanoma. Its regenerative properties, ability to modulate inflammation and promotion of epithelial healing make CAM an excellent addition to a surgeon’s armamentarium.
- References:
- Dalvin LA, et al. Cornea. 2021;doi:10.1097/ICO.0000000000002449.
- Shields CL, et al. Arch Ophthalmol. 2000;doi:10.1001/archopht.118.11.1497.
- Tanaka TS, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000737.
- For more information:
- Raymond I. Cho, MD, FACS, clinical professor and director of ophthalmic plastic and reconstructive surgery at The Ohio State University Wexner Medical Center, fellow of the American College of Surgeons and the American Society of Ophthalmic Plastic and Reconstructive Surgery, a retired Army colonel, former president of the Society of Military Ophthalmologists and current vice president of the North American Society of Academic Orbital Surgeons, can be reached at raymond.cho@osumc.edu.
- Emily Xu, MD, an ophthalmology resident at The Ohio State University Wexner Medical Center, can be reached at emily.xu@osumc.edu.
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